Provider Demographics
NPI:1659766012
Name:COLLINS, AUDRA
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 W UNIVERSITY DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 W WEST MAPLE RD
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3402
Practice Address - Country:US
Practice Address - Phone:248-624-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF0215393363LF0000X
MI4704281339363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily